A conversation I do not avoid

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Category : Medical Rants

The Most-Avoided Conversation in Medicine

I am not the only doctor who has had difficulty dealing with dying patients. Researchers who in the mid-1990s observed more than 9,000 seriously ill patients in five American teaching hospitals found substantial shortcomings in the care of the dying. More than a third spent at least 10 of their last days in intensive care. Among patients who remained conscious until death, half suffered moderate to severe pain. And fewer than half of their physicians knew whether or not their patients wanted to avoid cardiopulmonary resuscitation.

I believe (and hope) that the current generation of medical students and residents will do a better job than the author of this article. I have often blogged on this issue. The key to doing a better job is having academic physicians who specialize in palliative care.

I am fortunate to work in a VA with a dedicated team of palliative care physicians. We even have a dedicated ward – Safe Harbor. Because we have such good role models and colleagues, we consider palliative care in a wide variety of patients. We consider the various aspects of palliation on a regular basis.

Since our housestaff became exposed to palliative care, they have had a remarkable transformation. Our patients have DNR discussions. Our patients receive excellent pain management during end of life care.

Fortunately, our 3rd year students are exposed to these concepts during their internal medicine rotation. I personally encourage them to witness an interview with a dying patient that the palliative care team conducts. I personally have end of life discussions with patients on rounds (with the entire team in attendance).

This represents a paradigm shift at our institution. My colleagues tell me that this movement is growing rapidly in academic medicine. I hope that all students will learn these lessons.

My experience tells me that patients and families are generally very grateful for this attitude. Our patients now most often either die in the Safe Harbor environment or at home with hospice care. And that is a blessing.

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Comments (1)

I have seen this situation handled both very well and very badly. My then 46 year old brother died last January of liver failure at a large academic hospital. Soon after admission with no family, my parents were called in and a very frank discussion of the reality of what was going on took place. With no hope of recovery my brother was kept medicated and allowed to slip away when it was his time. No heroics. No questions of who would pull the plug since there was never a plug to pull.

My brothers experience was very different from a friend who passed away last February at 67. He had a very aggressive cancer and his constant battle was with his oncologist. His oncologist was very willing to hospitalize him, spend thousands of dollars of his insurance companies money, knowing there was no long term hope, and that in effect they were prolonging his pain. Hs oncologist told his wife he needed to be in the hospital on an IV, not out visiting his friends. After all, they could add two or three months to his life in the hospital.

His end of life battle was in trying to receive proper pain management and to die with dignity.

People are a lot more willing to have these discussions than most doctors realize. People are also much more concerned with the financial aspects of care at this stage of life. Spending countless dollars on a futile search for a cure that will never happen is not on the top of everyone’s list.

Be kind. Be honest. Be surprised at the positive response you will receive from the family and patient.

Steve Lucas

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